These programs support the consistent use of evidence-based, professional guidelines for diagnostic imaging procedures. They help reduce risks to patients and improve the quality, safety and appropriate use of imaging procedures.
Notification and prior authorization may be required for these advanced outpatient imaging procedures:
Nuclear medicine studies, including nuclear cardiology
Authorization is not required for procedures performed in an emergency room, observation unit, urgent care center or during an inpatient stay.
*Note: For Medicare Advantage benefit plans, prior authorization is not required for CT, MRI, or MRA.
These requirements apply to all providers subject to the UnitedHealthcare Administrative Guide. To review the complete protocol, please refer to the Outpatient Radiology Notification/Prior Authorization Protocol section in that guide.
This program is effective in Arizona, California, Florida, Kentucky, Louisiana, Maryland, Massachusetts, Mississippi, Missouri, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia, Washington and Wisconsin.
The following Commercial resource materials are inclusive of the UnitedHealthcare River Valley and NHP membership.
When you notify us of a planned service that is subject to the protocol, we’ll conduct a clinical review to determine if the service is medically necessary and covered, and will let you know our decision.
If the member's benefit plan does not require a clinical review and the service does not meet clinical guidelines, or if additional information is needed, we’ll let you know if you need to have a physician-to-physician discussion.